A code last week reminded me that the biggest problem with classroom ACLS is that it is too clean, too managed, too un-chaotic. Here’s a couple of recommendations to the AHA for inclusion in the next set of guidelines for ACLS curricula.

1. More people, smaller rooms. Codes almost never happen in big rooms, so you end up with 20-30 people cramming into a 10×10 (or smaller). I swear besides the code team, everyone else tends to show up. Housekeeping, dietary, looky-loo nursing staff with nothing better to do, extra docs not involved in the case, maybe a couple of pharmacists and an administrator. To best simulate that feeling of claustrophobia and having to work under such conditions, the schools hosting the classes should hire extras to crowd around you so there is barely enough room to work.

2. Auditory competition. It’s usually a cacophony of noise as people are barking orders, shouting back values, yelling at each other and general noise in a code. ACLS mock codes are just too quiet, like a quaint afternoon tea in the country. They’re full of thoughtful contemplation, “Hmmm…we gave Epi, CPR is in progress, let’s see what the next step should be.” Where usually it is, “What!!! Did you give EPi yet?!!!” and “GET ON THE CHEST!!!!” To solve this, using the extras mentioned above, have them loudly carry-on conversations to provide a sort of white noise effect and teach students to think with 10 different voices giving you information all at once.

4. Realistic dummies that either poop, pee or vomit during the code. Ever done CPR while trying to keep your scrubs out of vomit? Yeah, it’s difficult, the hands slip off of their position as the gloves slide over the vomit on the chest so it’s kind of like hitting a moving target. Also, the training should incorporate identification of emesis into the H’s & T’s differential diagnosis. Maybe call it T-H-Es? We’re trying to look for a causative reason, ID’ing dinner might be a good start, it’s usually easily viewed. One of the extras could smear chocolate pudding on the dummy with each rhythm check to add that extra layer of realism. To make it better, the manufactures of the dummies could add an optional module that uses the force of the compressions and triggered by breaths to spew liquid material out of the dummy’s mouth.

5. Re-organize the algorithms by using a drunken dart toss for each step, say every 2 minutes. Many times the actions are just so random it is like that. This way by using the toss method, random changes to the procedure would be accounted for and awaited thus allowing practioners to think ahead. Besides, wouldn’t playing darts in ACLS be awesome?

Finally,

6. Teach clean-up as part of post-recusitation care. We’ve all seen rooms after a code. Wrappers everywhere, boxes from meds strewn about, random pieces of detrisius tossed to the side of the bed, pieces for the intubation tray lodged in the computer keyboard, sharps hiding under piles of plastic and the puddles of body fluid. What should be taught is that everyone goes on break, leaving one person to clean up the mess. That job should be assigned with as much if not more importance than the compressors to ensure the rest of the team gets to take a break post-code.

If the AHA would consider incorporating these elements into ACLS training, it would make the providers so much more capable in handling the realities of the true in-hospital codes. Just sayin’.

editors note: your results may vary, data is compiled from triple-blinded, beer-goggled, non-placebo, peer un-reviewed observation of events on medical/telemetry/geri-psych nursing floors over a 5 year period of time.

That’s why every police/fire/parks & rec/ranger/scout leader should be trained in basic CPR. I’m not saying much more as it is too hard to say what truly happened, but that it sounds like this may have been averted.

We had a code the other night. It was by far the “best” code I’ve ever been privy to. No yelling orders, no standing around waiting, no egos, just a concerted effort to save a dying (well, dead) patient. The resident running the code was calm, cool and collected. As we did our interventions he worked through the H’s & T’s trying to figure out if we could fix anything. Outside of my ACLS megacode, I’ve never seen that. But moreso, he asked the staff if there was anything that we thought he had missed. And before he called it, he aksed if anyone else had any objections. Truly it was a team effort.

But for some reason I can’t seem to shake it off. I had no real connection to the patient, other than being the charge nurse. They weren’t one of our frequent flyers. But something reached ahold of me and won’t seem to let go.

Maybe it was the fact we found her already down in her room. Or the fact I felt the ribs snap under my palms. Or it was that we did CPR on her for 30 minutes, rotating between 2, then three of us. Or that we threw everything in the code cart at her, and some things that weren’t, but nothing seemed to help. Our CPR was some of the best I’ve ever seen/felt. We shocked her a total of 9 times. She got tubed incredibly quick. But it didn’t seem to matter.

For the last couple of nights, I’ve laid awake and thought about it. Re-running it over in my head, which then sparks memories of other codes and then to the memory of running in to see them performing CPR on my little girl. For some reason, this one cracked my shell. Like the title says, I can’t put words to the feeling.

Maybe though, it re-affirms that I am human and that I do care, something that I’ve been feeling a great distance from. Maybe I’ve grown cold over it all- something my wife mentioned in passing not too long ago. Maybe this nagging sense of malaise over this event is me re-examining myself over this coldness and cynicism and the realization that I’ve moved that direction has left me a little out of sorts. More than anything though, it serves as a reality check, a visceral reminder of what we do as nurses when things do go south.

I know with time this angst and malaise over it will fade. I’ll make peace with the way I feel about it, but like all the others, I’ll never forget.